Frank V. McL. Booth

Partial liquid ventilation in adult patients with ARDS: A multicenter phase I-II trial

OBJECTIVE: To evaluate the safety and efficacy of partial liquid ventilation (PLV) in adult patients with the acute respiratory distress syndrome (ARDS). SUMMARY BACKGROUND DATA: Previous studies have evaluated gas exchange and the safety of PLV in adult patients with severe respiratory failure whose gas exchange was partially provided by extracorporeal life support (ECLS). This is the first experience with adult patients who were not on ECLS. METHODS: Intratracheal perflubron in a total dose of 30.1 +/- 7.1 ml/kg was administered over a period of 45 +/- 9 hours to nine adult patients with mean age = 49 +/- 4 years and mean PaO2/FiO2 ratio = 128 +/- 7 as part of a prospective, multicenter, phase I-II noncontrolled trial. RESULTS: Significant decreases in mean (A-a)DO2 (baseline = 430 +/- 47, 48 hour = 229 +/- 17, p = 0.0127 by ANOVA) and FiO2 (baseline = 0.82 +/- 0.08, 48 hour = 0.54 +/- 0.06, p = 0.025), along with an increase in mean SvO2 (baseline = 75 +/- 3, 48 hour = 85 +/- 2, p = 0.018 by ANOVA) were observed. No significant changes in pulmonary compliance or hemodynamic variables were noted. Seven of the nine patients in this study survived beyond 28 days after initiation of partial liquid ventilation whereas 5 patients survived to discharge. Three adverse events [hypoxia (2) and hyperbilirubinemia (1)] were determined to be severe in nature. CONCLUSIONS: These data suggest that PLV may be performed safely with few related severe adverse effects. Improvement in gas exchange was observed in this series of adult patients over the 48 hours after initiation of PLV.

Clinical and economic outcome of patients undergoing tracheostomy for prolonged mechanical ventilation in New York state during 1993 : Analysis of 6,353 cases under diagnosis-related group 483

OBJECTIVE To examine and describe the relation between age and disposition in patients undergoing tracheostomy. DESIGN Retrospective analysis of a statewide database. SETTING All acute care hospitals in New York state. PATIENTS All patients (n = 6,353) > or = 18 yrs of age who were discharged from the hospital during 1993 with a final diagnosis-related groups code of 483. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The final disposition, according to six disposition codes (other acute care facility, residential healthcare facility, other healthcare facility, home, home healthcare services, and death) was examined for the entire population. Cost per case was assumed to equal the average statewide Medicaid rate. An inverse relation between survival rate and age was observed, which resulted in an age-related increased cost per survivor. Also, survivors in older age groups had an increased rate of discharge to residential healthcare facilities. There was a negative, albeit less marked, effect of older age on the rates of survivors discharged to home and to other healthcare facilities. CONCLUSIONS Care of patients who undergo tracheostomy for prolonged mechanical ventilation is expensive. The older the patient, the less satisfactory the outcome from an economic, clinical, and possibly social perspective.

Surgical management of complications of endoscopic sphincterotomy with precut papillotomy

We reviewed 574 endoscopic sphincterotomy procedures. Fifty-six precut papillotomies were performed. Presenting conditions included choledocholithiasis, cholangitis, benign and malignant papillary strictures, and stenosing papillitis. Complications were identified in 16 percent: perforation in 9 percent, pancreatitis in 5 percent, bleeding in 2 percent, and pancreatic abscess in 2 percent. One patient died. Six patients required operation for complications. Perforation of the duodenum or common bile duct seen within 8 hours was managed with drainage and closure of the perforation with minimal complications. Duodenal perforations operated on later than 8 hours required more extensive procedures. All these patients had significant post-operative complications. Three patients were managed nonoperatively. Precut papillotomy carries a significantly higher complication rate than conventional sphincterotomy. Our experience suggests that there is no place for conservative management of duodenal perforation.

Liver lacerations--a marker of severe but sometimes subtle intra-abdominal injuries in adults.

Experience with conservative management of solid viscus injuries from abdominal trauma in children has produced the impetus for a similar management in adults. To explore the implications of such a policy, we reviewed the records of 82 patients with hepatic injuries noted at laparotomy. Indications for laparotomy were positive findings on diagnostic peritoneal lavage (DPL) or CT scan, or a history of penetrating trauma. The liver injuries were graded according to severity: grade I, 19 patients; grade II, 20 patients (low severity = LS); grade III, 14 patients; grade IV, 6 patients (high severity = HS). Twenty-three injuries were not classified by the operating surgeon. Of the 53 patients with blunt hepatic trauma, 23 (43%) had concomitant injuries that required operative intervention. Twenty-nine patients had penetrating liver injuries. Fourteen (48%) had associated injuries requiring intervention. Patients most likely to have nonoperative management, those with grade I and grade II liver injuries (LS), comprised 48 of the total. In this subgroup there were 26 (54.2%) associated injuries requiring operative intervention. Shock could not be used as a factor to differentiate patients not requiring operative intervention. Nineteen of the LS patients requiring operative intervention secondary to associated injury were never in shock. In adult trauma victims positive DPL findings secondary to minor hepatic injuries that might not require operative intervention serve as a marker for associated injuries that do require operation. The risk of nonoperative management of hepatic injuries based upon radiologic diagnosis is not the result of complications from the hepatic injury.(ABSTRACT TRUNCATED AT 250 WORDS)

Utility of an oral examination in a surgical clerkship

To evaluate the utility of the oral examination in a surgical clerkship, we designed a prospective and randomized study to relate the subjective impressions of experienced examiners with an objective measure of cognitive knowledge. The examiners were asked to score the students performance as honors, high satisfactory, satisfactory, or unsatisfactory, according to their subjective impression of the students ability. Student performance was grouped according to oral examination performance. The cognitive performance in the honors group was significantly better than that of the other groups (Students t-test, p = 0.05). There was a significant difference in cognitive performance for oral examination groups throughout the rotations (analysis of variance, p = 0.000; Kruskal Wallis, p = 0.05). The oral examination is useful to identify a high level of cognitive achievement but cannot discriminate between groups of median to low competence. It should be used for educational feedback, career counseling, residency recommendations, and professional development.

The role of pediatric surgery in the medical school curriculum.

In most medical schools, exposure to pediatric surgery is presented as a subspecialty elective. We have offered it as an integral part of the surgical clerkship for 10 years in the belief that it provides an excellent educational environment. To confirm this concept, the quizzes (Q), final examinations (FE), and grades of students assigned to the pediatric surgical service were prospectively studied. All students (N = 139) in the surgical clerkship entered the study. Thirty-two students were randomly selected and assigned to the surgical service of a major pediatric hospital (P-Surg) for 50% of their clerkship. The other students (N = 107) were assigned to a variety of adult surgical services (G-Surg) and served as the control group. All students attended the same seminars, used the same educational materials, were examined with the same test items, and were evaluated by the same oral examiners. Test items were electronically scored and the database was analyzed on an IBM computer. The statistical analysis was performed using a Students t test and chi 2 analysis. There was no significant difference in the demonstrated cognitive performance and grades awarded to the two groups of students. We conclude that a pediatric surgical service provides an atmosphere that is educationally comparable to the adult general surgical service.

COMPUTERIZED PHYSIOLOGIC MONITORING

Computers can offer significant enhancement to the monitoring of the critically ill. Their value is derived from improved vigilance, better charting, and an opportunity to assess practitioner compliance with unit protocols. However, their true value can only be attained when they are integrated into a total information system.

A program for documenting competency during surgical residency

The Department of Surgery at the State University of New York at Buffalo (SUNY/Buffalo) has designed a competency program for surgical residents to provide focused graduate experience and create a database that is acceptable to the American Board of Surgery. It uses a computer program (ResSolution) to manage the database. The Advanced Trauma Life Support (ATLS) provider course is used to document trauma credentials. A total of 221 residents have achieved satisfactory trauma credentials within six months of entering the program. All of the senior residents (PGY4/5) have instructor status. In 12 months, 66 residents have participated in 10,203 surgical procedures in five consortium hospitals. The majority (81.5%) were performed by the resident with direct faculty supervision. This resident credentialing program documents the acquisition of clinical skills and provides a template on which graduate training can be formalized. It may improve resident cognitive performance by identifying knowledge domains that ...

Staff Communications and Credentialing in a Multisite Institution

Our surgical program is responsible for the education of over 60 residents in general surgery rotating among five major hospitals. Commitments to the service component of surgical education and the limitations of working hours of residents imposed by the state of New York have greatly increased the difficulties of effective communication between the faculty and the trainees. At the same time, certifying agencies such as the American Board of Surgery, the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), and the New York State Health Department are imposing ever more stringent standards of record keeping, supervision, and information communication upon the administrators of teaching programs. We have employed telecomputing in two areas to substantially enhance effectiveness in meeting these standards. A balanced and effective program in surgical education requires constant evaluation of the progress and case exposure of residents. In a multisite program, traditionally dependent on the flow of paper between sites, this has proved almost impossible to accomplish. Residency review committees now expect to see accurate statistics of operative experience and the degree of involvement of surgical residents on a case-by-case basis. Normative standards are being developed. Teaching programs that fail to capture the true extent of the operative teaching experience they offer run the risk of having their resident allocation cut, or their accreditation curtailed. This has led to the development of special-purpose databases to track resident experience. These are available in such packages as Res-SOLution.’ Other in-house packages developed by various academic centers have also been described.’.’ These flat-file databases, when appropriately used, enormously simplify the tasks of tracking, reporting, and collating resident exposure. Unfortunately, the general design and function of these systems fail to take full advantage of available technology. They essentially mimic the former paper-based systems and require an intermediate paper-based step for data entry and specialized clerical staff to transpose the hand-filled forms into the database; this vitiates the potential advantages of computerization. These drawbacks are serious in programs based in a single site; they become overwhelming when multiple hospitals are involved. The strongest motivation for training and advancement for a surgical resident is usually internal. Methods to encourage complete documentation of activities must build on this by positive feedback. Reliance on coercion or threat is less likely to be rewarding. When a system relies on the transmission of progress reports by the movement of paper, the manual entry of data into a remote system and the